Challenges Of Airway Management In A Patient With Maxillofacial Injury In A Resource Poor Environment.

Abstract

Maxillofacial injuries can be frightening. It often presents with disfiguring facial appearance. These injuries usually result from high velocity trauma. Advance Life Trauma Support (ALTS) recommends that, in management of patients with Life-threatening injuries, airway maintenance with cervical spine immobilization should be the first priority. Securing the airway in these patients is often difficult in spite of all modalities available, because these injuries are often complicated by injuries to various routes of intubation, associated C-spine injury, and high risk of regurgitation and aspiration. Difficult airway should always be anticipated and planned for. Good assessment of the injuries and careful formulation of airway management plan is very essential for better outcome.

Method
We report a 55yr old man who presented in a peripheral Hospital with scary facial avulsion involving half of the face, with associated mandibular fractures, multiple scalp lacerations and open fracture of the tibia and fibula, secondary to Road Traffic Accident (RTA). He was transferred to this facility after being rejected by other facilities within vicinity. He was one of the few survivor of a ghastly Vehicular motor accident. History could not be obtained, as the patient was still confused and there was no
eyewitness.

Examination revealed a confused patient, in painful distress, he is conscious with GCS of 13/15, with active bleeding from the facial injuries, scalp, and the mouth. The Right lower limb was splinted (had Fractured Tibia and Fibular). There was no CSF otarrhea nor rhinorrhea. BP ranged between 100/60 - 110/70. Pulse 110-126 bpm (after resuscitation), SPO2 96-98% (room air) with respiratory rate of 20 breaths/min, no respiratory difficulty. Airway assessment revealed multiple abrasion around the neck, bleeding from the angle of the mouth, with exposed mobile, fractured, right mandible. Urgent blood grouping and cross-matching was the only investigation one could assess. He was premedicated with intravenous Ranitidine and Metorclopromide.

Difficult airway was anticipated and planned for. Though there was no Fibreoptic laryngoscope, and other visual aids of securing the airway, and no ENT surgeon within the facility, however we had Resus I-gel LMA, Classic LMA, intubating bouggie, and a 16G cannular with a connector, as back up. The airway was successfully secured via nasotracheal intubation using the conventional Macintosh laryngoscope, after induction with Ketamine, with Cricoid pressure application and In-Line stabilization of the C-spine Patient had a successful surgery. Extubation was done 4 days later and patient made a good recovery.

Conclusion
Airway management in Maxillofacial injuries is challenging irrespective of the environment and equipment available. Clinical status and features of the trauma dictates the approach for securing the airway. Various steps of difficult airway management need to be planned before airway management is initiated. Familiarizing with the available airway devices is necessary for better outcome as seen in this management.